http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(3): 195–201 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2014.966808

ORIGINAL ARTICLE

Interprofessional mental health training in rural primary care: findings from a mixed methods study Olga Heath1,4, Elizabeth Church3, Vernon Curran4, Ann Hollett2, Peter Cornish1, Terrence Callanan2, Cheri Bethune2 and Lynda Younghusband1 1

University Counselling Centre, Memorial University, University Centre, St. John’s, Newfoundland, Canada, 2Faculty of Medicine, Memorial University, St. John’s, Newfoundland, Canada, 3Faculty of Education, Mount Saint Vincent University, Halifax, Nova Scotia, Canada, 4Faculty of Medicine, Centre for Collaborative Health Professional Education, Memorial University, St. John’s, Newfoundland, Canada Abstract

Keywords

The benefits of interprofessional care in providing mental health services have been widely recognized, particularly in rural communities where access to health services is limited. There continues to be a need for more continuing interprofessional education in mental health intervention in rural areas. There have been few reports of rural programs in which mental health content has been combined with training in collaborative practice. The current study used a sequential mixed-method and quasi-experimental design to evaluate the impact of an interprofessional, intersectoral education program designed to enhance collaborative mental health capacity in six rural sites. Quantitative results reveal a significant increase in positive attitudes toward interprofessional mental health care teams and self-reported increases in knowledge and understanding about collaborative mental health care delivery. The analysis of qualitative data collected following completion of the program, reinforced the value of teaching mental health content within the context of collaborative practice and revealed practice changes, including more interprofessional and intersectoral collaboration. This study suggests that imbedding explicit training in collaborative care in content focused continuing professional education for more complex and chronic health issues may increase the likelihood that professionals will work together to effectively meet client needs.

Continuing professional education, interprofessional, mental health training, mixed-methods, primary care, rural

Introduction There are very few mental health specialists practicing in or consulting to rural communities (Hutten-Czapski, 2001; Macfarlane, 2005; McIlwraith & Dyck, 2002; National Rural Health Association, 1999; Pawlenko, 2005; Rohland & Rohrer, 1998). Mental health care in rural areas is generally provided by family physicians or other primary health care providers, many of whom lack the necessary time, knowledge or skills to provide effective mental health treatment (Barbopoulos & Clark, 2003; Bethune, Worrall, Freake, & Church, 1999; Macfarlane, 2005; Thorngren, 2003). Many health professionals report feeling underprepared to manage the complex social, psychological and psychiatric needs in their communities (Yuen, Gerdes, & Gonzales, 1996). Rural mental health professionals report greater struggles with health care barriers, including lack of resources, training constraints and professional isolation (Brems, Johnson, Warner, & Roberts, 2006; Coll, Kovach, Cutler, & Smith, 2007; Roberts, Battaglia, & Epstein, 1999). As a result, rural mental health care providers often report role overload, heightened stress and burnout (Coll et al., 2007; Moore, Sutton, & Maybery, 2010).

Correspondence: Olga Heath, University Counselling Centre, Memorial University, University Centre, St. John’s, Newfoundland A1C 5S7, Canada. E-mail: [email protected]

History Received 19 September 2013 Revised 2 July 2014 Accepted 15 September 2014 Published online 7 October 2014

Collaborative practice in mental health care may offer a means of improving access and quality of care in rural settings while simultaneously providing needed support to rural health care professionals. In a collaborative model, providers from a variety of professions and sectors work together with consumers, families and caregivers to promote mental health and provide co-ordinated services (Gagne´, 2005). There is growing evidence to suggest that collaborative mental health care may improve the quality of mental health services delivered in primary care settings and contribute to positive patient outcomes (Craven & Bland, 2006; Macfarlane, 2005). Coll et al. (2007) note that when rural mental health professionals create an intersectoral consultation group by collaborating with teachers, clergy, police officers, judges and paraprofessionals, the result is a reduction in burnout and an increase in available resources. According to Bosco (2005), successful collaborative mental health care requires education in evidence-based practice and experiential learning in interprofessional collaboration. Gauntlett (2005) developed and implemented a two-year postgraduate training program in the UK designed to improve skill acquisition and application of mental health intervention techniques in the community with a multidisciplinary audience. The two factors that were most important in facilitating transfer of learning to practice were the credibility of trainers and training alongside colleagues with whom they might collaborate. Several authors have suggested the need for increased access to continuing

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interprofessional education for rural providers and a greater emphasis during training at the university level on the unique challenges faced by rural practitioners (Campbell, Caffrey, & Manoff, 2007; Coll et al., 2007; Moore et al., 2010). However, there has been limited research on factors influencing collaborative mental health care in rural communities, and Craven and Bland (2006) have identified this as an area for further study. This paper describes the impact of the Rural Mental Health Interprofessional Training Program (RMHITP), a continuing education initiative implemented in Newfoundland and Labrador, Canada on interprofessional knowledge, attitudes, perceptions and practice.

Background The RMHITP was developed based on feedback from Family Physicians in a study of mental health training at Memorial University’s Family Practice Residency Program (Bethune et al., 1999). It was considered innovative in several respects: (a) it was longer than most rural mental health training programs (multiple sessions over approximately 20 weeks); (b) the training comprised both didactic evidence-based mental health intervention material and interactive experiential teaching tools and (c) the program was designed to simultaneously promote skill development in mental health interventions (stages of change model, motivational interviewing, solution-focused therapy, cognitive-behavioral approaches, assertive community treatment and crisis intervention) and increase interprofessional and intersectoral practice (Table I). Some outcomes from the program related to participant satisfaction (Heath et al., 2008) and impact on mental health knowledge and confidence (Church et al., 2010) have already been reported.

The RMHITP was offered in six rural communities to an interprofessional/intersectoral group of participants. The first two sessions were presented on-site and focused on the characteristics of effective interprofessional teams and the development of collaborative relationships. The eight remaining sessions were presented via videoconference and consisted of didactic presentations focused on the mental health issues outlined above, followed by interprofessional/intersectoral small-group skillbuilding and case-based exercises. In each session, participants explored the challenges and benefits of interprofessional/intersectoral mental health practice for their professional work. At the start of each session, participants discussed how they applied previously learned material. The program was approved by the College of Family Physicians of Canada for Mainpro M1 continuing education credits.

Methods The perceived impact of the RMHITP was evaluated using sequential mixed-methods (Driscoll, Appiah-Yeboah, Salib, & Rupert, 2007) and quasi-experimental design. We used this methodology to allow for more depth and richness of understanding of the impact of the RMHITP through the combination of surveys and interviews and focus groups. Participants Participants in this study were recruited purposively by Community Facilitators who were health professionals in Primary Care leadership positions. They invited individuals from a variety of professions and sectors who they considered likely to benefit from attendance. Participants came from a wide variety of sectors, including health care, community agencies, justice and schools. Invitations were not tracked and thus there are

Table I. RMHITP session content and skill development exercises. Topic Interprofessional team development

Session content  Recognizing an effective interprofessional team  Working at different stages of team development

Building effective relationships Stages of change and motivational interviewing (two parts)

 What is important in a working relationship?  How to be an active listener in any relationship  Understanding resistance to change  How to work with different stages of change

Cognitive-behavioral approaches (two parts)

Solution-focused interventions (two parts)

 Evidence-based techniques for working with people not ready to change  Basic evidence-based techniques with depression and anxiety

 Working with adolescents, couples and families using solution-focused interventions  Setting workable goals

Assertive community treatment (ACT)

 ACT and working with a chronically mentally ill population  ACT in a rural area

Crisis intervention

 Psychiatric emergency versus mental health crisis  How to identify and intervene in a mental health crisis

Skill development exercises  ‘‘Talking Wall’’ exercise: learning about what others provide in mental health intervention  Case presentation and discussion on challenges and rewards of working collaboratively  Active listening in challenging situations  Case and practice of active listening skills  Part 1. Identifying behaviors which characterize each stage of change  How to move forward to the next stage using examples  Part 2. Role-play of a motivational interviewing approach  Part 1. Identifying faulty cognitions  Part 2. Demonstration of several forms of relaxation  Role-play of a CBT approach  Part 1. Role-play of solution-focused interviewing  Identifying exception-finding in video  Part 2. Role-play of use of the ‘‘Miracle Question’’  Role-play of solution-focused approach for group goal-setting  Identifying the role of each profession in an ACT approach to a case  Brainstorming about the value of a local ACT approach  Discussion of whether a case example is a crisis and why  Role-play of intervention using principles explained

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no data on refusal rates. Participants were those who were interested and available to attend sessions and recognizing that work and personal commitments as well as weather affecting travel would impact ability to attend, there was no expectation that participants attend all sessions. Community facilitators were also responsible for distributing pre- and post-intervention surveys. Data collection Quantitative measures Survey data were gathered prior to the first session and at the end of the program. The surveys comprised demographics and two validated scales. The post-survey also included a program feedback questionnaire that evaluated participant perceptions of the program. The first validated scale, the Attitudes Toward Health Care Teams scale was adapted from Heinemann, Schmitt and Farrell (2002) with minor changes to wording to reflect the focus on mental health care and was renamed Attitudes Toward Interprofessional Mental Health Care. Psychometrics for the original scale show a Cronbach’s alpha of 0.83 indicating acceptable internal consistency and content validity indices of 0.95 for appropriateness of items and 0.91 for assignment of items to domains.1 The adapted scale was reviewed for this study by an interprofessional panel (psychiatrist, family physician, psychologists and education consultant) for content validity. The adapted scale consists of 14 items measuring views about the advantages and disadvantages of interprofessional mental health care measured on a Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree) with 3 as a midpoint (Neutral). The second validated scale, the Perception of Interprofessional Collaboration scale is a seven-point semantic differential scale adapted from Clark’s (1994) work with gerontology teams measuring perception of collaborative skills as well as the value of interprofessional teamwork. It does not specifically refer to collaboration in mental health care but more generally references interprofessional teamwork. The original inventory was reviewed by experts familiar with teamwork issues for wording and face validity, and for the present study, the adapted scale was reviewed for content validity by an interprofessional panel (psychiatrist, family physician, psychologists and education consultant). The post program questionnaire included 12 items of which five gathered perceived impact of the program on participants’ knowledge and understanding about collaborative mental health care and the roles of various professionals in the provision of that care. The statements were rated on a Likert Scale from 1 (Strongly Disagree) to 5 (Strongly Agree) with a midpoint of 3 (Neutral). Qualitative data Community facilitators and professionals in all six communities were invited to participate in the focus groups. There were eight focus groups, two with the community facilitators with three participants in each, and a focus group in each of the six communities, with from three to six participants. The focus groups included both individuals who had attended the program consistently as well as those who attended only a few sessions. Overall, nine different professions were represented: nurse (n ¼ 2), nurse practitioner (n ¼ 4), social worker (n ¼ 6), community development specialist (n ¼ 1), youth regional co-ordinator (n ¼ 1), school counsellor (n ¼ 1), police officer (n ¼ 1), 1

As part of the development of the scale, four experts rated items on appropriateness and assignment to subscales. These values represent the level of agreement.

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occupational therapist (n ¼ 1) and dietician (n ¼ 1). There were six professions absent from the focus groups. The most notable absence was the physician group. In addition, in-depth individual interviews were also conducted with 12 professionals who had participated in the program in one community in order to provide more depth of detail than could be gleaned from a focus group. There was representation from all nine professions, including a family physician, who been part of the program in that community. Data analysis Quantitative analysis Demographics were analyzed using SPSS (Version 16) (Armonk, NY) to provide a participant profile. Reliability analyses were conducted for the standardized measures used in this study and the Cronbach’s alpha reliability coefficient was 0.82 for the Attitudes Toward Interprofessional Mental Health Care and 0.83 for the Perception of Interprofessional Collaboration, indicating adequate internal consistency for both measures. Pre-post paired sample t-tests (SPSS, Version 16) were used to examine changes in Attitudes Toward Interprofessional Mental Health Care and perceptions of general interprofessional collaboration. The Program Feedback Questionnaire was analyzed using descriptive statistics (SPSS, Version 16) to calculate participants’ overall mean self-reports of program impact on knowledge about interprofessional mental health care. Qualitative analysis The interviews and focus groups were transcribed with all identifying details removed. Data were analyzed using the MAXQDA (2007) (Berlin, Germany) qualitative software package. Both the interview and focus group data sets were examined to identify comments made about the effects of the program on participants’ collaborative mental health practice. These were grouped according to broad categories and then examined using thematic analysis (Braun & Clarke, 2006). Themes were given more weight if they were discussed in more than one data set, across a number of communities and by a variety of professions. Ethical considerations Ethics approval was granted by the Human Investigations Committee at Memorial University before the study commenced.

Results Quantitative perspectives Sample A total of 125 professionals attended at least one session. Of the 125 total attendees, 103 completed a pre-intervention survey and 66 completed a post-intervention survey. Using participantgenerated identifying codes from the surveys, it was possible to match the pre- and post-intervention surveys of 49 professionals; these 49 surveys make up the basis for all matched comparisons included for analysis. Seventy percent of the participants (87/125) attended the first day of on-site sessions; only nine of these (7% of total attendees) did not return for any subsequent sessions. The 49 participants who completed both the pre-post measures were not significantly different from the total sample on any of the demographic characteristics: age, gender, community, years of professional experience or number of mental health clients seen weekly (Table II). However, those who completed both the pre-post measures had higher rates of attendance than participants overall with a mean attendance of 7.2/10 sessions, SD 2.6,

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Table II. Demographic characteristics for all participants and participants completing pre- and post-intervention surveys.

All participants (N ¼ 125) Participant demographics

N

%

Age Under 30 18 14.4 30–39 40 32.0 40–49 45 36.0 50–59 21 16.8 Over 59 1 0.8 Gender Female 106 86.9 Male 16 13.1 Community Bonne Bay 13 12.9 Harbour Breton 15 14.9 Port aux Basques 21 20.8 Goose Bay 15 14.9 Placentia 24 23.8 St. Anthony 13 12.9 Years of professional experience Less than 1 year 6 4.9 1–5 years 20 16.3 6–10 years 24 19.5 11–15 years 12 9.8 16–20 years 22 17.9 21–25 years 18 14.6 425 years 21 17.1 Number of mental health clients seen weekly None 11 9.3 1–5 63 53.4 6–10 21 17.8 11–20 16 13.6 420 7 5.9

Table III. Attendance by profession for all participants and participants completing pre- and post-intervention surveys (total number of sessions ¼ 10).

Completed pre- and post-intervention surveys (N ¼ 49) N

%

4 17 22 5 1

8.2 34.7 44.9 10.2 2.0

43 6

87.8 12.2

8 4 14 4 9 10

16.3 8.2 28.6 8.2 18.4 20.4

3 11 4 7 9 6 8

6.2 22.9 8.3 14.6 18.8 12.5 16.7

6 28 10 2 3

12.2 57.1 20.4 4.1 6.1

Completed pre- and post-intervention surveys All participants

Profession

N

Mean # Sessions (SD)

Nurse 37 5.7 Social worker 35 6.0 Community development worker 8 2.8 Nurse practitioner 7 6.4 Police/justice 7 1.6 Physician 7 4.1 Clergy/pastoral care 4 2.8 Clerical staff 4 3.5 Ambulance attendants/paramedic 3 1.3 School counsellors/psychologist 3 8.7 Youth regional coordinator 3 3.0 Dietician 2 4.5 Occupational therapist 2 6.0 Recreational therapist 2 5.5 Pharmacist 1 4.0 Total 125 5.02

N

(2.8) 16 (2.9) 15 (2.3) 2 (2.4) 2 (0.5) 1 (2.6) 1 (2.9) 1 (1.7) 1 (0.6) – (2.3) 2 (1.7) 2 (2.1) – (5.7) 1 (3.5) 1 (–) – (2.9) 45a

Mean # Sessions (SD) 7.6 7.4 6.0 7.5 2.0 7.0 7.0 6.0 – 10.0 5.0 – 10.0 8.0 – 5.02

(2.6) (1.9) (5.7) (0.7) (–) (–) (–) (–) (–) (0.0) (5.7) (–) (–) (–) (–) (2.9)

a

Four participants did not indicate their profession.

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compared with a mean of 5.0/10 sessions, SD 2.9, for all participants (Church et al., 2010). There were no significant differences in Attitude or Perception change scores or postknowledge scores for community, profession, age or years of experience. Based upon those who filled out the pre-survey, the majority (86%) of participants was female and 77% were between the ages of 30 and 50. Based on data obtained from the 125 individuals who attended at least one session, there were 15 different professions represented (Table III). Changes in Attitudes Toward Interprofessional Mental Health Care Forty-nine participants completed this measure pre- and postprogram. A paired samples t-test revealed a significant increase in scores from the pre-intervention survey (M ¼ 4.04, SD ¼ 0.41) to the post-survey (M ¼ 4.21, SD ¼ 0.38; t(48) ¼ 3.02, p ¼ 0.00). The eta squared statistic (0.16) indicates a large effect (Figure 1). Changes in perception of interprofessional collaboration Forty-nine participants completed this scale pre- and postprogram. A paired sample t-test revealed an improvement in perceptions from the pre-survey (M ¼ 5.85, SD ¼ 0.68) to the post-survey (M ¼ 5.99, SD ¼ 0.70), but this increase was not statistically significant; t(48) ¼ 1.63, p ¼ 0.11) (Figure 1). Program Feedback Questionnaire A total of 66 participants filled out the collaborative mental health care knowledge section of the Program Feedback Questionnaire.

6 Mean Score

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5.85

Pre

5.99

Post

5 4.04

4.21

4 3 2 1 Perceptions of IP Collaboration (p = 0.11 ns)

Attitudes Towards IP Mental Health Teams* (p = 0.00, eta = 0.16)

* This scale has a maximum score of 5

Figure 1. Changes in perceptions of interprofessional collaboration and Attitudes Toward Interprofessional Mental Health Care (N ¼ 49).

Over 90% of respondents agreed or strongly agreed with both statements related to the program’s positive impact on their understanding of teamwork in interprofessional mental health care. Participants also strongly endorsed statements related to the program’s positive impact on the development of better understanding of one’s own role (82.6% agreed or strongly agreed) and other professions’ roles (91.3% agreed or strongly agreed) in collaborative mental health care (Table IV). Qualitative perspectives Participants’ comments clustered around two main themes: first, they were already strong proponents of interprofessional care before they began the program and viewed the program as a ‘‘reminder’’ of their belief in the efficacy of interprofessional practice. Second, the primary benefit of the program was to help them develop new knowledge, insights and referral networks for interprofessional mental health practice.

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Table IV. Participant rating of intervention impact on knowledge and understanding of interprofessional mental health care.

Item This training program has enhanced my understanding of IP mental health care This training has enhanced my understanding of IP teamwork in mental health care I learned a great deal about the role of my profession/occupation as a part of an IP mental health care group I learned a great deal about the role and expertise of other professions/occupations as members of an IP mental health care group

Strongly disagree N%

Disagree N%

Neutral N%

Agree N%

Strongly agree N%

A/SA %

Mean

–

2 (2.9)

–

29 (42.6)

37 (54.4)

97.0

4.49

–

2 (2.9)

2 (2.9)

33 (47.8)

32 (46.4)

94.2

4.38

–

2 (2.9)

8 (11.6)

38 (55.1)

19 (27.5)

82.6

4.16

–

2 (2.9)

3 (4.3)

32 (46.4)

31 (44.9)

91.3

4.38

Already proponents of the benefits of interprofessional care All of the professionals in the focus groups and interviews were strong supporters of interprofessional collaboration. A number commented that they believed collaboration was more critical in rural areas: there are fewer resources so professionals need to rely more on one another. For example, an occupational therapist stated: The team here works very well too because the majority of the team ends up on site, in this building. So this site is very good for inter-professional collaboration. It’s easier when it’s a smaller place . . . Because we are rural, because we don’t have specialists on site, we do rely on each other a little bit more. In all six communities, professionals reported that they were actively engaged in interprofessional collaboration and interdisciplinary teamwork before the program, and this was maintained after the program. Participants commented that the sessions on interprofessional practices helped to affirm their belief in the efficacy of their current approach, and ‘‘reinforce’’ that they were on the right track. As one professional said: ‘‘My opinion didn’t really change after doing this program because I think I had already formed it and I thought it worked well. This just reinforced that things can work better if you work as a team.’’ Others noted that the program reminded them to pay attention to the core principles of collaborative practice, in particular that they needed to take time to plan their collaborations so that ‘‘all the appropriate people have been included and people are given ample opportunity to make a contribution to the team’’. Broadening scope of interprofessional mental health practice Many of the participants used the word ‘‘broaden’’ to describe the effect of the program. Often they would say that they already had a mental health referral network in place before the program, but the program helped them to develop and build new relationships. While there had been good intra-institution collaborations, particularly within health, there was now more contact across sectors. For example, in dealing with mental health issues, professionals in the health system were now working more closely with the police, those in the school system had established links with health professionals, and community-based workers felt more connected to professionals in the hospital. Participants said they were now more likely to call professionals in other systems, both for consultations and referrals. There was recognition that good mental health care often demands the expertise and cooperation of multiple systems – health, justice, community agencies and the school system. Professionals found it very helpful to learn about other professionals’ scope of practice in relation to mental health.

In one session, participants were asked to describe what they knew about the mental health expertise of different professions, so, for example, a school psychologist would listen as other professionals stated what they thought a school psychologist did, and then the psychologist would explain her or his role. Many of the professionals commented that they both learned what other professionals could do and had an opportunity to educate others about their areas of expertise. For example, a nurse practitioner stated: School counsellors, that was an eye-opener for me. I didn’t realize they did as much as they did – the guidance counsellors at the schools. So it was just interesting to hear what other disciplines are doing. It’s good referral points. As well as knowing what other professionals did, it was also important to know who they were. That is, the personal connection was critical. A number of the participants said they now felt more ‘‘comfortable’’ with a broader range of professionals, and this increased the likelihood that they would contact those people regarding mental health questions: I would be far more comfortable making referrals knowing all the faces. This is a fairly transient community . . . So having the people around the table and understanding who they are and exactly what they do and what they don’t do really helped me. (Psychologist) A number of the participants said they gained a better understanding of the mental health services that were available in their community. One participant described it as building a ‘‘map’’ of mental health resources. For newer professionals and those who had recently moved to the community, the program was an opportunity to develop a sense of the mental health landscape. A police officer commented: It’s not always easy to understand what other agencies’ roles are or procedures are or policies are. So I think it’s been helpful that way, and I know for the other officer that came with me to the last couple sessions, being inexperienced as she is, I think it was a good eye opener to her as to what exactly is available within the community. In three communities, the program was a catalyst for new mental health collaborations. This occurred primarily in the communities which had the highest levels of attendance. For example, in one community, a social worker and a police officer collaborated around an issue with a mental health client that the police officer had been called into to deal with. In another community, program participants

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formed a small intersectoral group to advocate for a new mental health nurse position in order to establish a modified Assertive Community Treatment model (this treatment model was taught as part of the program).

Discussion It is well recognized that collaborative mental health care results in better services and helps to improve patient outcomes (Craven & Bland, 2006) and that rural practitioners feel underprepared to provide mental health care (Macfarlane, 2005). When multiple primary health care providers across different sectors collaborate effectively, they are better able to prevent, detect, intervene early and follow-up with mental health problems (Kates et al., 2011). They are also at an advantage with regard to managing crises and coordinating care not only for the patient, but also for the caregiving network – a critical part of mental health care (Kates et al., 2011). This study focused on increasing rural practitioners’ knowledge and skills with mental health content as well as their knowledge and awareness regarding interprofessional care for mental health issues. Although there have been studies documenting the value of mental health training for rural practitioners (Bourke et al., 2004; Steele, Lochrie, & Roberts, 2010), and some have included a multidisciplinary audience (Gauntlett, 2005) with others having the development of collaborative care as their objective (Mildred, Brann, Luk, & Fisher, 2000) none that we are aware of have simultaneously trained in collaborative practice skills. The literature has identified the need for more research in this area (Craven & Bland, 2006). The present study adds to the field by reporting the positive impact of an intervention that combined an interprofessional, intersectoral mental health skillsbased continuing education program with content and interactive exercises designed to increase collaborative practice. The findings also highlight some key strategies that rural mental health professionals draw upon to provide mental health services in light of the challenges of practicing in rural areas. Both the quantitative and qualitative results suggest that although participants perceived themselves as practicing collaboratively prior to the program, the focus on collaboration within the context of learning mental health skills had a positive effect. Bourke et al. (2004) have highlighted that effective team practice is viewed as a positive feature of rural health practice as it can be developed more easily in smaller health care settings. The imperative for team practice in rural areas is the result of the challenges associated with resource limitations, access to services and professional isolation (Brems et al., 2006). Rural health providers have fewer options for referrals and must work with other local health providers in providing health services. The RMHITP was welcomed by the participants as a means for reinforcing their collaborative efforts, expanding their professional network by acquainting themselves with newer providers and learning more about the roles of other health professionals in the provision of mental health care. Interestingly, there was low attendance at sessions (Table III), particularly for some professions, most notably Ambulance attendants/Paramedics and Police/ Justice. This is most likely related to these professionals choosing to attend those sessions most applicable to them (e.g. Crisis Intervention and Assertive Community Treatment) combined with other factors such as work schedules and personal commitments. The quantitative results revealed significant pre-post changes in attitudes Toward Interprofessional Mental Health Care and strong participant endorsement of the impact of the program on knowledge and understanding of the importance of collaboration in providing mental health services. D’Souza (2000) also reported high levels of satisfaction, confidence and competence from rural

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health professionals (community mental health workers and GPs) who participated in a distance continuing education program on mental health offered via videoconferencing technology. Given the challenges of access to professional training opportunities and professional isolation, rural health care professionals welcome opportunities for professional development (Brems et al., 2006). However, self-reported non-mental health collaborative skills and value for teamwork, already high prior to the intervention, did not significantly change which likely reflects the pre-existing motivation and capacity in rural communities to practice collaboratively as described in Bourke et al. (2004). The findings suggest that the integration of mental health continuing education within the framework of collaborative practice is valuable. Participants viewed themselves as competent and active collaborators prior to the program but felt that the training opened up new avenues for interprofessional and intersectoral partnerships in providing mental health care that had the potential to benefit clients and the community. An important benefit of participation in the RMHITP, identified by both regular and sporadic attendees, appeared to be the opportunity to learn about other professionals’ scope of practice in relation to mental health and a better understanding of the mental health services available in the community. These benefits were highlighted by a number of interview respondents. An increased understanding of other health professional’s roles is a key interprofessional collaboration competency and is likely to positively influence coordination of mental health care. These results may be related to the explicit content and experiential focus on the importance of providing collaborative mental health care. Throughout the program, participants were asked to consider how interprofessional/intersectoral evidencebased mental health practice could improve their client outcomes and job satisfaction and to report back changes tried in their practice. The findings may also be related to the consistent facilitator and the length of the program (20 weeks) which ensured that participants had time to form interprofessional/ intersectoral relationships and understand the role each could play in mental health care. In relation to study limitations, the quasi-experimental design of this study did not include a control group which limits the ability to attribute all changes to the intervention. Another factor limiting generalizability of the findings was the comparatively small number of pre- and post-survey matches which may be explained by the fact that, due to weather conditions, work schedules and/or personal issues, many professionals did not attend one of the first few or the last sessions (at which pre- and post-surveys were distributed) and that attendance at all sessions was not mandatory, nor was completion of the pre- and postintervention surveys. Purposive sampling was used to generate the participant group and thus professionals who held unusually positive attitudes toward interprofessional collaboration may be over represented. Community facilitators invited those professionals for whom the training would be relevant, and we do not know the refusal rates or whether the professionals who attended were representative of all the professionals in the community. However, the Community Facilitators, who had an in-depth knowledge of mental health care in their community, were able to recruit a broad range of professionals involved in mental health, many of whom were outside the health care system, and this represented a significant strength of the study. There were five professions who had attended sessions from whom we did not get any follow-up qualitative data and it is possible that those professions were impacted differently from the professions from whom we gathered data. The practice changes which were reported in the interviews and focus groups are

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self-reported and were not verified, and there was neither objective assessment of practice change nor any measure of impact at the system level. Future studies could include objective measures of impact on client care and interprofessional interaction as well as mental health care system impact.

Concluding comments The results of this study suggest that the RMHITP format of providing interactive, expert presentations on collaborative mental health in an interprofessional, intersectoral context to rural professionals holds promise as a possible model for providing mental health training in rural settings. Providing mental health training in an interprofessional, intersectoral learning environment, over an extended period of time, allows professionals to develop stronger relationships and new ways of practicing collaboratively. This has the potential to lead to more effective mental health care in rural settings.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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